Big toe fusion This leaflet aims to answer your questions about having big toe fusion surgery. It explains the benefits, risks and alternatives, as well as what you can expect when you come to hospital. If you have any further questions, please speak to a doctor or nurse caring for you.
What is big toe fusion surgery? This operation fixes the bones together at the base of the big toe (first metatarsophalangeal joint). What happens during big toe fusion surgery? Big toe fusion surgery can be done as a day surgery procedure unless you have other significant medical problems that mean you may need to stay in hospital overnight. You will usually have a general anaesthetic (be asleep). A cut is made over the joint. The joint surfaces are cut out and prepared so that the big toe sits in a good position. The bones are then fixed together with metalwork (either screws or a plate and screws). The wound is closed with stitches. Procedures for the smaller toes may be performed at the same time through separate cuts over those toes. The foot and ankle is then bandaged up. Why should I have big toe fusion surgery? The most common reason to have this surgery is for severe arthritis of the big toe, where the toe is already stiff and painful. In the fusion operation, the joint surfaces are removed so that the two bones will heal together. If there is no movement at the joint there will be no pain. However, the joint will be permanently stiff. People can walk fairly normally with a stiff toe as it does not hurt, but women will notice a difficulty in wearing a heel of more than one inch high. 2
What are the risks? In general, the risks of any operation relate to the anaesthesia and the surgical procedure itself. In most cases you will have a general anaesthetic. You will be able to discuss this with the anaesthetist before surgery and he/she will identify the best method for your individual case. For more information about this please see our leaflet, Having an anaesthetic. If you do not have a copy, please ask us for one. The main surgical risks are listed below. The full list of risks will be explained by the surgeon treating you. Swelling: Your foot will swell after surgery as part of the response to surgery and the healing process. It may take more than six months for the swelling to go down completely. It is important to elevate your foot in the early stages, when not moving. Non-union: There is a 10% chance that your bones will not heal together (unite). This may need further surgery. This risk can be up to 50% if you smoke, and can be higher in patients with diabetes. Mal-union: This is when your bones have healed together but not in the correct position, causing your big toe to point inwards, outwards or be slightly raised. This can cause the toe not to function correctly. If this happens it may be necessary to have revision surgery to break the bone again and realign. The chance of this happening is rare. 3
Stiffness: The big toe will be stiffer than before surgery. This will limit the size of heel you can wear on your shoe. The surgery will allow for a small heel (one inch). If this is not acceptable, you should discuss with your surgeon before going ahead with surgery. Infection: The cuts usually heal within two weeks, but may leak a small amount of fluid. In a small number of cases (less than one in 10 patients), the wounds may become infected and need antibiotics. Pain: Some patients experience pain under the smaller toes after big toe fusion surgery as the weight is transferred this way (metatarsalgia). This is often helped with a special shoe insole. A small number of patients may experience Chronic Regional Pain Syndrome, a chronic disease characterized by severe pain, swelling and changes in the skin, which may persist beyond the first few weeks following surgery. Metalwork: You may be able to feel the metalwork in your foot, in which case after six months you may have a smaller operation to remove it. By then the fusion will be solid so the screws are no longer needed as the bone will have bridged the former site of the joint. Shoes with a soft upper or even a rocker sole shoe can help. 4
Are there any alternatives? Simple non-surgical measures, such as a stiff soled or soft shoe should be tried before undergoing surgery. If the joint damage is not too severe, sometimes a cheilectomy may be performed before fusion surgery, where the joint is cleared of excess bone to try to maintain movement and improve the pain. Often, the damage is too severe to be treated with a cheilectomy, and fusion surgery is the best option. How can I prepare for big toe fusion surgery? Please refer to one of the following leaflets which will provide all of the necessary information you will need before your operation: The surgical admission lounges (SAL) and day surgery units (DSU) at Guy s and St Thomas Hospital Having an anaesthetic. If you do not have a copy, please ask us for one or see our website at www.guysandstthomas.nhs.uk You should make arrangements to be collected from the hospital. Someone should stay with you overnight if you have a general anaesthetic and your operation is a day case. You will need some time off work after the surgery. This will be at least four to six weeks but may be longer if you have a manual job. Your surgeon will discuss this with you. We advise you speak to your employer before surgery to make plans. 5
Consent - asking for your consent We want to involve you in decisions about your care and treatment. If you decide to go ahead, you will be asked to sign a consent form. This states that you agree to have the treatment and you understand what it involves. If you would like more information about our consent process, please speak to a member of staff caring for you. Will I feel any pain? There will be some pain after the surgery. During your operation local anaesthetic may be injected into your foot to reduce the pain after the operation. You will be given medicines to take home to control the pain. The nurse will go through the medicines with you, including how often and when to take them. There will be a combination of strong and weak painkillers. It is important that you continue to take painkillers as advised after your surgery. However, if you have little or no pain you may not need to take the painkillers. If your pain does not settle, then you can either be reviewed in your scheduled outpatient appointment or you should seek further advice and management from your GP. 6
What happens after big toe fusion surgery? The day of your surgery When you have recovered from the anaesthetic, the physiotherapists will give you crutches and a special orthopaedic shoe. This will allow you to put weight on the back/heel of your foot, but not put the front/ball. This will protect the area that has been operated on. Most patients can go home on the same day as the surgery. What do I need to do after I go home? This is a general guide only. Patients will progress and recover from their surgery at different rates. If your surgeon gives you different advice, then you should follow that. Days 1-7 after surgery The local anaesthetic in the joint will start to wear off the day after surgery, so you will need to start taking painkillers. You should keep the foot elevated when not walking for the first two weeks after the operation. Whenever the foot is put down, it will swell and become sore. It is normal to see mild bruising and some dry blood on the foot. Your foot and ankle will be heavily bandaged to protect it and to help reduce the swelling. The gauze bandage which is applied in the operating theatre will stay on for two weeks. There will not normally be a plaster cast. Do not get your bandaged foot wet. 7
Days 8-14 after surgery Continue to elevate the foot as much as possible, when not mobilising. You may walk short distances within your home or to a car from this week, ensuring you are wearing the special orthopaedic shoe. In week two you can start working from home but you must try and keep the foot elevated. By the end of this week the post operative pain will have significantly reduced. You will be seen approximately two weeks after your operation in the nurse dressing clinic in the orthopaedic outpatient clinic. This appointment will be made and posted to you. During this appointment the wounds will be checked and any stitches removed. We can advise you at this appointment regarding your return to work. Days 15-21 after surgery If you have a sedentary job (desk job) and are able to elevate your leg, you will be able to return to work two weeks after your surgery. If you have a heavy manual job it will be at least eight weeks, and possibly three months, before you can return to work. You should not drive, unless surgery was on your left foot and you have an automatic car. If surgery was on your right foot or you have a manual car, it will be six weeks before you can drive. Motor insurance companies vary in their policies, so check with them first. Days 22-28 after surgery You should remove all the remaining wound dressings at home by soaking the dressings off in the bath or 8
shower. You should apply moisturiser around the healing wound. Once the wound is completely healed, you should apply the moisturiser over the wound as well. You can massage the scar to soften it and make it less sensitive. Keep wearing your orthopaedic shoe and wear a large sock to stop your shoe rubbing on the scar. At this stage, your foot will still be swollen. Do not expect to fit into your normal shoes. 5-6 weeks after surgery You will have a further appointment to see a member of the team in clinic. You may have an x-ray at this appointment to check the bones are healing. You can start wearing a pair of wider, looser fitting shoes following this appointment. A good option includes trainers, with loosened laces, croc style shoes or soft suede boots. Bring a pair with you to your clinic appointment. 6-12 weeks after surgery Your mobility will continue to improve although you should avoid walking long distances. You can usually return to work after six weeks if you have a light manual job. You may start driving again, but check with your insurance company first. You can start gentle low impact exercise and activities for example cycling, exercise bike and cross training. Gradually increase your activity level with time. High impact exercise, for example running, can start at 12 weeks. You should speak to your surgeon about this if you are unsure. 9
3-12 months after surgery It may take six months to return to your normal sporting activity level. Your foot may continue to be swollen for up to a year following this surgery. Patients are advised not to fly within 12 weeks of foot surgery. This is due to the increased risk of blood clots during this time. What should I do if I have a problem? If you experience any of the following symptoms, please contact your GP or go to your nearest A&E department: increasing pain increasing redness, swelling or oozing around the wound site fever (temperature higher than 38 C). If you have an infection at any time during your recovery, either suspected by you or diagnosed by your GP or an A&E doctor, please contact your consultant s secretary on 020 7188 4443. 10
Contact details If you have any questions or concerns about big toe fusion surgery; please contact the following (Mon-Fri, 9am-5pm) Your consultant s secretary on 020 7188 4443 The clinical nurse specialist call the hospital switchboard on 020 7188 7188 and ask for the bleep desk. Ask for bleep 2567 and wait for a response. This will connect you to the clinical nurse specialist directly. Please contact your GP or go to your local A&E department if you have any urgent medical concerns outside these hours. Pharmacy Medicines Helpline If you have any questions or concerns about your medicines, please speak to the staff caring for you or call our helpline. t: 020 7188 8748 9am to 5pm, Monday to Friday Your comments and concerns For advice, support or to raise a concern, contact our Patient Advice and Liaison Service (PALS). To make a complaint, contact the complaints department. t: 020 7188 8801 (PALS) e: pals@gstt.nhs.uk t: 020 7188 3514 (complaints) e: complaints2@gstt.nhs.uk 11
Language and accessible support services If you need an interpreter or information about your care in a different language or format, please get in touch: t: 020 7188 8815 e: languagesupport@gstt.nhs.uk NHS 111 Offers medical help and advice from fully trained advisers supported by experienced nurses and paramedics. Available over the phone 24 hours a day. t: 111 NHS Choices Provides online information and guidance on all aspects of health and healthcare, to help you make choices about your health. w: www.nhs.uk Get involved and have your say: become a member of the Trust Members of Guy s and St Thomas NHS Foundation Trust contribute to the organisation on a voluntary basis. We count on them for feedback, local knowledge and support. Membership is free and it is up to you how much you get involved. To find out more, and to become a member: t: 0800 731 0319 e: members@gstt.nhs.uk w: www.guysandstthomas.nhs.uk/membership Leaflet number: 3775/VER2 Date published: April 2017 Review date: April 2020 2017 Guy s and St Thomas NHS Foundation Trust 12